What are the NICE (National Institute for Health and Care Excellence) guidelines for managing pediatric patients with dengue?

NICE Guidelines for Pediatric Dengue Management

NICE (National Institute for Health and Care Excellence) has not published specific guidelines for dengue management in children. Dengue is primarily endemic to tropical and subtropical regions outside the UK, and NICE focuses predominantly on conditions relevant to UK clinical practice. The comprehensive evidence available comes from the World Health Organization, American Academy of Pediatrics, and other international societies that have established evidence-based protocols for pediatric dengue management 1, 2.

Applicable International Guidelines for Pediatric Dengue

Since NICE guidelines do not exist for this condition, clinicians should follow the established international consensus recommendations:

Initial Assessment and Risk Stratification

Monitor for warning signs that predict progression to severe dengue:

• High hematocrit with rapidly falling platelet count 1
• Severe abdominal pain and persistent vomiting 1
• Lethargy or restlessness 1
• Mucosal bleeding 1
• Hepatomegaly, which is independently associated with severity in multiple studies 3

Assess for shock indicators:

• Tachycardia, hypotension, poor capillary refill, and altered mental status 1
• A rise in hematocrit of 20% along with continuing platelet drop signals impending shock 4

Fluid Management Algorithm

For children WITHOUT shock:

• Oral rehydration is first-line treatment 1, 2
• Avoid routine bolus IV fluids in patients with severe febrile illness who are not in shock, as this increases fluid overload risk without improving outcomes 2

For children WITH dengue shock syndrome (grades III-IV):

• Administer 20 mL/kg isotonic crystalloid (Ringer's lactate or 0.9% saline) over 5-10 minutes 1, 2, 5
• Reassess immediately after each bolus 2, 5
• If shock persists, repeat crystalloid boluses up to 40-60 mL/kg in the first hour 2, 5
• High-quality evidence from a randomized trial of 383 children shows Ringer's lactate is equally effective as colloids for moderate shock 6

Escalation to colloids:

• Reserve for severe shock unresponsive to crystalloids 2, 7
• 6% hydroxyethyl starch is preferable to dextran 70 due to fewer adverse reactions, despite similar efficacy 6
• Colloids achieve faster shock resolution (RR 1.09,95% CI 1.00-1.19) and require less total volume (31.7 mL/kg vs 40.63 mL/kg for crystalloids) 2, 5

Critical Phase Monitoring (Days 3-7)

Watch for clinical indicators of adequate perfusion rather than laboratory values alone:

• Normal capillary refill time, absence of skin mottling 1, 2
• Warm and dry extremities with well-felt peripheral pulses 1, 2
• Return to baseline mental status and adequate urine output 1, 2
• Daily complete blood count to track hematocrit and platelet trends 2, 5

Management of Refractory Shock

Vasopressor selection based on shock phenotype:

• Cold shock with hypotension: epinephrine as first-line 2, 5
• Warm shock with hypotension: norepinephrine as first-line 2, 5
• Target age-appropriate mean arterial pressure and maintain ScvO2 >70% 2, 5

Preventing Fluid Overload

Stop aggressive fluid resuscitation when signs of overload appear:

• Hepatomegaly, pulmonary rales, or respiratory distress 2, 5
• Switch to inotropic support instead of continuing fluids 2, 5
• Evidence from 96 children shows aggressive shock management combined with judicious fluid removal decreased pediatric ICU mortality from 16.6% to 6.3% 2, 8

Hospitalization and ICU Criteria

Admit to hospital:

• Moderate to severe dengue, especially with respiratory distress or hypoxemia 1

Admit to ICU:

• Requiring ventilatory support or impending respiratory failure 1
• Sustained tachycardia, inadequate blood pressure, or altered mental status 1

Critical Pitfalls to Avoid

• Never use aspirin or NSAIDs due to increased bleeding risk 2
• Never continue aggressive fluids once overload develops, as this worsens outcomes 2, 5
• Never miss the critical phase (days 3-7) when plasma leakage rapidly progresses to shock 2
• Never delay initial fluid resuscitation in confirmed shock, as dengue shock can cause death within 12-24 hours without prompt treatment 4
• Avoid drainage of pleural effusions or ascites when possible, as this can precipitate severe hemorrhage and circulatory collapse 4

Blood Product Transfusion

Transfuse only for significant bleeding:

• Blood products (packed red cells, fresh frozen plasma, platelets) are indicated for active hemorrhage with hemodynamic compromise 1, 2
• Prophylactic platelet transfusion based on counts alone is not recommended 4